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S:_N JOAQUIN COU'L TY F TRONMENTAL HEALTH DIVIS <br />lL-\,STERFILE RECORD EiFOR-NIATION FORA (EH 00 69) <br />New EH Program at Existing Facility ❑New EH Pro am and New Facility <br />Facility ID � ��q�55 Program Record ID <br />Facility Address ;'LITS W. \b&e 1 d -C A'VQ.YLI-l!L . M0L41 bLCGL <br />(Please Check the appropriate description and specify size, number of units and Pertinent information.) <br />FOOD PROGRAM (1600) <br />❑ Restaurant: Searing Capacity Square Footage Food Handlers Course required: YEs ❑ No ❑ <br />❑ Commissary ❑ Dry storage only ❑ with Food Preparation ❑Vending Machines —Number of Units <br />❑ Retail Market --Square footage ❑ with Meat Market only ❑ Multiple Departments ❑ Prepackaged Goods Only <br />❑ :Mobile Food Vehicle ---Make Vehicle Type Color <br />Registration License m Sticker <br />❑ Mobile Food Prep Unit—Make Vehicle Type Color <br />Registration T License R Sticker T <br />❑ Temporary Food Facility --Dates of operation from to Cl Ice Plant <br />❑ Special Event - Dates of operarion from to ❑ Produce Stand <br />DAIRY PROGRAM (2000) <br />❑ Grade A Dairy ❑ Grade B Dairy ❑ Milk Dispenser—Number of Containers in Multi -Head Unit <br />CUPA ❑ State Facility Surcharge (2399) <br />KAZARDOUS WASTE PROGRAM (2200) <br />❑ Hazardous Waste Generator ------------------Tons Generated Per Year <br />Tiered Permitting Facility ❑ Conditionally Authorized (CA) ❑ Conditionally Exempt (CE) <br />❑ Permit -By -Rule Fixed Uait ❑ Permit -By -Rule Household Hazardous Waste <br />ABOVEGROUND STORAGE TANK FACILITY (AST) (2390)—Number of AST <br />UNDERGROUND STORAGE TANK (UST) PROGRAM (2300) Use USTA and B forms <br />HOUSING PROGRAM (2400) <br />❑ HoteV}totel------- Number of UnitsP <br />Jail or Exempt Institution Number of Units <br />Employee Housing (2700) Use Employee Housing/Labor Camo loplication Form <br />SITE MITIGATION (2900) UNDERGROUND INJECTION CONTROL(3000) <br />Cl Environmental Assessment ❑ UST -CAP Site ❑ Local HW Cleanup Site ❑ NPLJSEP Cleanup Site ❑ UIC Site <br />❑ .abandoned HW Site ❑ non-NPL/SEP Cleanup Site ❑ RWQCB Cleanup Site ❑ Water Quality Remediation Site <br />RECREATIONAL HEALTH PROGRAM (3600) <br />Number of Pools/Spas at Facility Cl Pool Cl Spa ❑ Out of Service Pool/Spa ❑ Natural Bathing Area <br />VECTOR CONTROL PROGRAM (4000) <br />❑ Poultry Farm Maximum number of birds ❑Fennel <br />TATTOO BODY PIERCING PERMANENT COSMETIC PROGRAM (4100) <br />❑ Tattooing (412 1) ❑ Body Piercing (4120) 11Permanent Cosmetics (4122) <br />LIQUID WASTE PROGRAM (4200) <br />❑ Pumper Vehicle—Registration # License T Capacity Vehicle T <br />❑ Pumper Yard ❑ Package Treatment Plant ❑ Chemical Toilets Number of Units <br />SOLID WASTE PROGRAM (=4400) <br />C1 Landfill C3 Transfer Station C1 Ag / Cannery Waste Site C3 Sludge/Ash Site <br />❑ Waste Tire Facility ❑ Compost Facility ❑ Process/Recycle Facility ❑ CIA Landfill Site <br />❑ Refuse Vehicles —Number of Units ❑ Dumpsters > 20 cu yd —Number of Units ❑ FarmfRanch Cleanup Site <br />MEDICAL WASTE PROGRAM (4500) <br />C3 Primary Care ❑ Acute Care C1 Skilled Nursing 13 Large Generator C3 Small Generator ❑Limited Hauler <br />❑ Transfer Station ❑ Veterinary Clinic ❑ Common Storage Facility —❑ 2 - 10 ❑ 11 - 60 —❑ > 60 generators <br />PUBLIC WATER SYSTEM PROGRAM (4600) Use PWS ERV069 Blue Application Form <br />EMERGENCY NOTIFICATION FOR THIS FACILITY AND/OR PROGRAM <br />CONTACT PERSON CS Day Ph Night Ph <br />PROGRAM l <br />I:ISPEC-rOR $ <br />❑ Check # <br />2;y t V FEE _ <br />PERNirr VALID <br />AMOUNT PAID <br />❑ Surcharge FEE ❑ Other FEE <br />to ❑ Food Handler__ <br />Date <br />❑ Cash REVM-%VED BY l.[A.lI ,� hI2�1DD ACCOt .MING OFFICE <br />EH 0069 PINK FOFLM.doc <br />INVOICE T <br />Date ; <br />Rev. 07/07199 <br />